Research on MORE

In the first Stage 1 randomized controlled trial (RCT) of MORE was conducted with alcohol use disorder (AUD) patients in a long-term residential therapeutic community. Results from this pilot RCT (N=53) demonstrated MORE’s effects on addiction mechanisms including alcohol attentional bias and autonomic recovery (i.e., heart rate variability) from alcohol cue-exposure (Garland et al., 2010). Having demonstrated promise as an addictions treatment, MORE was then tested in a 5-year Stage 3 RCT (N=180) at the same residential therapeutic community in a sample of formerly homeless men with co-occurring substance use disorders (SUD) and psychiatric disorders. MORE outperformed cognitive-behavioral therapy (CBT) and treatment-as-usual (TAU) in reducing drug craving and PTSD symptoms (Garland et al., 2016). MORE was modified as a treatment for prescription opioid misuse among chronic pain patients and tested in a Stage 2 RCT (N=115). After treatment, long-term prescription opioid users receiving MORE were significantly less likely than participants in an active control group to exhibit opioid misuse symptoms consistent with opioid use disorder (OUD) (Garland et al., 2014). In this trial, MORE was also found to significantly reduce chronic pain severity and functional interference, increase positive emotions (Garland, Bryan, et al., 2017), and restructure reward related mechanisms, as indicated by decreased opioid attentional bias (Garland et al., 2017), reduced opioid cue-reactivity (Garland, Froeliger, et al., 2014), and increased autonomic and neurophysiological responses to natural reward stimuli (Garland, Howard, et al., 2017; Garland et al., 2015). Shortly thereafter, a Stage 1 pilot neuroimaging trial (N=13) of MORE as a treatment for smoking cessation found similar evidence of restructuring reward processing via fMRI measures of brain reward system function (Froeliger et al., 2017). Later, two additional Stage 1 RCTs of MORE were completed that suggest that the effects of MORE may be extended into treatment for behavioral addictions. In a pilot RCT (N=30), MORE was shown to significantly reduce symptoms of internet gaming disorder (Li, Garland, et al., 2017). In another pilot RCT (N=51) of MORE as an intervention for obesity among cancer survivors, MORE significantly improved facets of interoceptive awareness and decreased food attentional bias, the latter of which was associated with increased physiological responsiveness to natural reward cues (Thomas et al., 2019).

More recently, a second Stage 2 RCT (N=95) of MORE for opioid-treated chronic pain patients found that MORE significantly reduced opioid misuse behaviors and pain severity by increasing a range of positive psychological factors, including positive affect, savoring, meaning in life, and self-transcendence (Garland, Hanley, Riquino, et al., 2019). In this trial, MORE was also shown to significantly decrease opioid dose, which was predicted by increasing heart rate variability during mindfulness meditation (Garland et al., 2020). A Stage 1 RCT (N=30) of MORE as an adjunct to methadone maintenance treatment of OUD found MORE to significantly reduce days of heroin and other illicit drug use (Cooperman et al., 2021) and to decrease momentary craving while enhancing self-control over craving (Garland, Hanley, Kline, et al., 2019). In another Stage 1 RCT (N=51), MORE was shown to significantly reduce opioid craving and psychological distress among pregnant women receiving medications for OUD (MOUD) (Reese, 2020).

To augment these clinical findings, Dr. Garland conducted a series of randomized experiments which were published in the high impact journal Science Advances, showing that MORE reduced neurophysiological indices of drug cue-reactivity and enhanced natural reward responsiveness in the human brain (Garland et al., 2019). These findings provide strong support for the hypothesis that MORE can restructure reward responses underpinning addiction. Additional EEG experiments found that MORE reduces anhedonia by increasing sensitivity to natural rewards (Garland et al., 2021) and decreases opioid use by amplifying frontal midline theta oscillations during mindfulness meditation (Hudak et al., 2021).

Finally, Dr. Garland completed a NIH R01-funded full-scale RCT of MORE as a treatment for opioid misuse among people with chronic pain, which was published in the top medical journal JAMA Internal Medicine (Garland et al., 2022). In this trial, 250 opioid misusing chronic pain patients (62% of whom had full-blown OUD) were treated with MORE or a supportive psychotherapy control condition in a primary care setting. Nine months after the end of treatment, the MORE group evidenced a 45% reduction in opioid misuse, more than doubling the effect of standard supportive psychotherapy, and 36% of patients were able to reduce their opioid use by half or greater. In addition, 50% of people treated with MORE achieved clinically significant reductions in pain. At the same time, the MORE group showed reduced depression, emotional distress, and PTSD, as well as opioid craving through the 9-month follow-up. Also, participants in MORE reported significant increases in positive emotions, meaning in life, and the sense of self-transcendence, coupled with enhanced autonomic responsiveness to natural rewards and improved self-regulation of opioid cue-reactivity. Finally, MORE increased frontal midline theta EEG activation which in turn mediated the effect of MORE on reducing opioid misuse, indicating that MORE reduces addictive behavior by strengthening cognitive control and restructuring reward processing in the brain. These latter mechanistic findings are forthcoming.

Across these studies, 868 participants have been randomized to MORE or various control conditions including supportive group psychotherapy, CBT, exercise and nutrition counseling, medications for opioid use disorder (MOUD), and usual care. The past decade of research demonstrates that MORE is an evidence-based treatment for addiction and its comorbidities.

Furthermore, multiple additional RCTs are now underway in the United States and Europe to test the efficacy and mechanisms of MORE as a intervention for: a) opioid misuse in veterans, b) illicit opioid use disorder, c) chronic low back pain in civilians and active duty military personnel, d) chronic knee pain in active duty military personnel undergoing knee replacement surgery; e) fibromyalgia, and f) smoking cessation. These studies include full-scale efficacy trials and later stage comparative effectiveness trials that will help to advance the implementation and dissemination of MORE as an empirically-supported intervention.

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